Payment of community health workers
Authors: Madeleine Ballard, Margaret Odera, Shreya Bhatt, Beth Geoffrey, Carey Westgate, Ari Johnson
Journal: The Lancet Global Health (2022)

We applaud Karen Hanson and colleagues from the Lancet Global Health Commission on financing primary health care for their excellent work showing that countries must invest more and better in primary health care.1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar We were dismayed, however, by their characterisation of "whether" to pay community health workers as a "key financing policy choice" in section 1 of the report.1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar We wonder: is the same true of doctors? Nurses? What about the esteemed members of the Commission? Do the various consultancies, academies, and foundations at which they are employed face similar policy choices? Demanding that individuals volunteer in order to access health care for themselves, their family, and their community is an act of coercion. As the authors themselves note in panel 18, WHO—based on the international agenda for decent work (including Sustainable Development Goal [SDG] 8) and efforts to redress the gender disparities (including Sustainable Development Goal [SDG] 5)—strongly recommends paying community health workers.2Cometto G Ford N Pfaffman-Zambruni J et al.Health policy and system support to optimise community health worker programmes: an abridged WHO guideline.Lancet Glob Health. 2018; 6: e1397-e1404Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar The International Labour Organization does likewise.3Addati L Cattaneo U Esquivel V Valarino I Care work and care jobs for the future of decent work. International Labour Organization, Geneva2018Google Scholar Indeed, the predominant focus of the report's sections related to community health workers sections is on how, rather than whether, to pay community health workers. The issue of whether to pay community health workers can no longer be framed as a policy choice about which reasonable minds can disagree. Community health workers from south Asia to southern Africa have long demanded fair compensation; it is well past time to cease giving those blocking their efforts technocratic cover. The problem of unpaid community health workers is widespread. Although figure 8 of the report1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar suggests that nearly 60% of community health workers in low-income and lower-middle-income countries received no salary, other estimates—those looking at all community health workers rather than solely those delivering services on behalf of the government—suggest that on the continent of Africa, the figure could be as high as 85%.4Nepomnyashchiy L Westgate C Wang A Olsen H Yadav P Ballard M Protecting community health workers: PPE needs and recommendations for policy action. Centre for Global Development, Washington, DC2020Google Scholar As one of the community health worker authors of this letter notes, many of her Kenyan colleagues have grown old without without receiving any financial compensation. Meanwhile, in these same countries, community health workers address up to 50% of the malaria burden5Ballard M Johnson A Mwanza I et al.Community health workers in pandemics: evidence and investment implications.Glob Health Sci Pract. 2022; 10e2100648Crossref PubMed Scopus (1) Google Scholar and, in multiple areas, were able to maintain speed and coverage of community-delivered care during the COVID-19 pandemic6Ballard M Olsen HE Millear A et al.Continuity of community-based healthcare provision during COVID-19: a multicountry interrupted time series analysis.BMJ Open. 2022; 12e052407Crossref Scopus (2) Google Scholar while producing a social and economic return of US$10 for every $1 invested in them.7Dahn B Woldemariam A Perry H et al.Strengthening primary health care through community health workers: investment case and financing recommendations.http://www.healthenvoy.org/wp-content/uploads/2015/07/CHW-Financing-FINAL-July-15-2015.pdfDate: July 13, 2015Date accessed: July 18, 2022Google Scholar Like Hanson and colleagues, we acknowledge that securing sustained financing for community health programmes, including for community health worker payment, is a challenge. To solve this challenge, we must first recognise that whether is the wrong question, and focus together on how. We declare no competing interests. The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care (PHC) into sharp focus. PHC is the best platform for providing basic health interventions (including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open Access